This information is used solely as an aid and will not be released without your knowledge and consent.

* Required

Name
*

First and Last Name

This is a required question

Birth Date
*

This is a required question

Address
*

This is a required question

City
*

This is a required question

State
*

This is a required question

Zip
*

This is a required question

Phone Number
*

This is a required question

Email
*

This is a required question

Personal Physician
*

This is a required question

Personal Physician Phone Number
*

This is a required question

Physical Activity Readiness Questionnaire
*

If you check “yes” for any question #1-#6, you must receive clearance from your physician prior to participating in this exercise program. Please have your physician complete a “Physician Clearance” Form.

Yes

No

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

2. Do you feel pain in your chest when you do physical activity?

3. In the past month, have you had chest pain when you were not doing physical activity?

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by change in your physical activity?

Have you had or do you presently have any of the following conditions?

Yes

No

Rheumatic fever

Recent operation

Edema (swelling or ankles)

High blood pressures

Injury to back or knees

Low blood pressure

Seizures

Lung disease

Heart attack

Fainting or dizziness

Diabetes

High cholesterol

Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) nocturnal dyspnea (shortness of breath at night)

Shortness of breath at rest or with mild exertion

Chest pains

Palpitations or tachycardia (unusually strong or rapid heartbeat)

Intermittent claudication (calf cramping)

Pain, discomfort in the chest, neck, jaw, arms, or other areas

Known heart murmur

Unusual fatigue or shortness of breath with usual activities

Temporary loss of visual acuity or speech, or short term numbness or weakness in one side, arm, or leg

Other family history

Please enter one response per row

Explain any items marked "yes."

Medical History, Past and Present

This is a required question

Medical Conditions
*

Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.) In addition, please identify at what age the condition occurred.

Yes

No

Heart attack

Heart operation

Congenital heart disease

High blood pressure

High cholesterol

Diabetes

Other major illness

Please enter one response per row

Explain any items marked "yes."

Medical Conditions

This is a required question

Activity History

How were you referred to Spokane Aerial?
*

This is a required question

Please answer the following questions.
*

Yes

No

Have you ever worked with a personal trainer before?

Have you had a physical examination within the past 12 months?

Do you participate in a regular exercise program at this time?

Can you currently walk 4 miles briskly without fatigue?

Can you currently do 2 pushups (not on knees)?

Have you ever performed resistance training in the past?

Do you have any injuries (bone or muscle disabilities) that may interfere with exercising?

Do you smoke?

Do you have a high amount of stress in your personal life?

Are you employed?

Do you consider your job to be high stress?

Do you consider yourself overweight?

Do you consider your overall diet healthy?

Do you eat at restaurants more than once a week?

Please enter one response per row

Please describe your own assessment of your health.
*

This is a required question

Why are you taking this class?
*

This is a required question

What are your exercise goals for this class?
*

This is a required question

Please check the box below if you are in agreement.
*

I fully and accurately completed the above Medical Information section for the Spokane Aerial Performance Arts conditioning and performance program and have no physical condition that would prevent or hinder my participation, other than those disclosed. In the event of any injury or illness while attending SAPA, I authorize SAPA and its employees to administer first aid, transport me to a hospital and initiate medical treatment if necessary.

This is a required question

Please check the box below if you are in agreement.
*

I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS HEALTH QUESTIONAIRE/APPLICATION BY READING THIS BEFORE SIGNING IT.

This is a required question

Please enter your full name.
*

This is a required question

Please check the box below if you are in agreement.
*

I certify that this is my signature and I have fully informed myself of the contents of this registration information form and agreement by reading all the above before signing it.